Immunosuppressive strategies in face and hand transplantation: a comprehensive systematic review of current therapy regimens and outcomes

Abstract

BackgroundRecipients of Vascularized Composite Allotransplants require effective immunosuppressive therapy to prevent graft rejection. This systematic review summarizes the current body of literature on immunosuppressive regimens used in face and hand transplants while summarizing their outcome in terms of rejection, renal failure, and infections.MethodsA systematic search of electronic databases was conducted to identify relevant studies from 1998 until July 1st, 2023. We included all studies that discussed immunosuppressive strategies in face and hand transplant recipients according to PRISMA.ResultsThe standard triple maintenance therapy was mostly adjusted due to nephrotoxicity or high incidence of rejection. The most common alternative treatments utilized were sirolimus (25/91; 27.5%) or everolimus (9/91; 9.9%) following hand- and photophoresis (7/45; 15.6%), sirolimus (5/45; 11.1%) or belatacept (1/45; 2.2%) following face transplantation. Episodes of rejection were reported in 60 (65.9%) of hand- and 33 (73%) of face transplant patients respectively. Graft loss of 12 (13.2%) hand and 4 (8.9%) face transplants was reported. Clinical CMV infection was observed in 6 (6.6%) hand and 7 (15.5%) face transplant recipients.ConclusionsBased on the herein presented data, facial grafts exhibited a heightened incidence of rejection episodes and CMV infections. Facial mucosa adds complexity to the immunological graft composition highlighting the need of individualized immunosuppressive regimens and further research.

Exploring Costimulatory Blockade-Based Immunologic Strategies in Transplantation: Are They a Promising Immunomodulatory Approach for Organ and Vascularized Composite Allotransplantation?

“…However, a biopsy is the investigation that ensures a definitive diagnosis. If confirmed, treatment is adjusted based on severity, using high-dose corticosteroids in mild to moderate cases [ 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 ]. Anti-thymocyte globulin may be used as a rescue strategy in corticosteroid-resistant or severe rejections [ 133 ].…”

“…Agents used in face and upper limb transplants can be seen in Table 2 , with usage frequency (%) in each of the immunosuppressive stages [ 131 ].…”

“…In transplants that also have a skin component, topical agents have been used to control mild rejection episodes, even without the need to increase the intensity of systemic immunosuppressive therapy. The topicals used are steroid compounds and tacrolimus [ 19 , 37 , 131 , 144 ]. In VCAs, acute rejection can be reversed if timely detection and correct treatment are initiated.…”

“…Agents used in face and upper limb transplants can be seen in Table 2, with usage frequency (%) in each of the immunosuppressive stages [131]. Triple therapy with tacrolimus, MMF and steroids is the standard protocol for maintenance immunosuppression in VCA recipients.…”

“…Immunosuppressive agents used in face and upper limb transplant in induction and maintenance phases (%-frequency of usage)[131].…”